New South Wales Combined High Schools Sports Association

Singles & Pairs Championships

Sport : NSWCHSSA Girls and Boys Singles & Pairs Championships

Date: Wednesday 6 June 2018 and Thursday 7 June 2018

Venue: Warilla Bowling Club

Completed applications to gavin.holburn@det.nsw.edu.au by Monday 28 May 2018.

Tick box Event nominated for:

Official (Singles Marker)

Please submit your application to the NSWCHSSA convener by email: gavin.holburn@det.nsw.edu.au

1. Student details please print clearly

Student Full Name:

Parents/Caregiver Full Name:
Address and postcode:
Date of birth:
School:
Regional Sports Association: (e.g. Riverina)
School Sports Organiser’s email:

Contact information please print clearly

Home telephone:
Work telephone:
Mobile phone address:
Email address:
New South Wales Combined High Schools Sports Association
2. Medical Details

Medicare Number: Exp date:

The date of my child’s last tetanus injection was:

My child is allergic to:

Does your child have an ASCIA action plan? YES / NO.

If YES a copy must be attached to this consent form.

Has your child suffered a head injury / concussion in the last 10 days? YES / NO.
If YES a medical clearance must be attached.

Medical or special needs

Please detail any medical or special needs which the team manager should be aware of, including any
behaviour management or other specialised plans. (copies of plans to be attached).

Important Information: In the event of injury, no personal injury insurance cover is provided by the NSW
Department of Education for students in relation to school sporting activities, physical education lessons or any
other school activity. The Department’s public liability cover is fault-based and limited to breaches by the
department of its duty of care to students that may result in claims for compensation.

Parents and caregivers are advised to assess the level and extent of their child’s involvement in the sport
program offered by the school, school sport zone, region and state school sport associations when deciding
whether additional insurance cover is required prior to their child’s involvement in the program. Personal
accident insurance cover is available through normal retail insurance outlets. Parents who have private
ambulance cover need to check whether that cover extends to interstate travel and make additional
arrangements as considered appropriate.

The NSW Supplementary Sporting Injury Benefits Scheme, funded by the NSW Government, provides limited
cover for serious injury resulting in the permanent loss of a prescribed faculty or the use of some prescribed
part of the body. The Supplementary Scheme does not cover medical expenses or dental costs .Further
information can be obtained from www.sportinginjuries.com.au Further information regarding student accident
insurance and private health cover is provided at:
https://app.education.nsw.gov.au/sport/Home/PolicyAndGuidelines?cache_id=30fbc
 Student name:
New South Wales Combined High Schools Sports Association

4. Travel details (Tick  the appropriate box.)

Please note: Where travel arrangements are organised, all team members must travel with the Official
Team to the championship

My child WILL travel privately with: to and from the championship

5. Privacy Notice
The personal information provided on this permission note, will be used and disclosed by the Department of
Education for general administration, communication with parents or carers and matters relating to the health
safety and welfare of your child in connection with your child’s participation at this event or for any other
purpose required or permitted by law. The provision of this information is voluntary but your child may not be
able to participate if it is not provided. This information will be held securely and disposed of securely when
no longer needed. You may correct personal details recorded on the form at any time by contacting the team
management.
Publishing student information: The Department of Education may publish or disclose information about
your child for the purposes of sharing his/her experiences with other students, informing the school and
broader community. This information may include your child’s name, age, information collected during this
event such as photographs, sound & visual recordings of your child.
The communications in which your child’s information may be published or disclosed include but are not
limited to:
Public websites of the Department of Education including the School Sport Unit website at
https://app.education.nsw.gov.au/sport
the Department of Education intranet(staff only), blogs and wikis
Department of Education publications including the school newsletter, annual school magazine and school
report, promotional material published in print and electronically including on the Department’s websites
Official Department and school social media accounts on networks such as YouTube, Facebook and Twitter.
Local and metropolitan newspapers and magazines and other media outlets.
Parents should be aware that when information is published on public websites and social media channels it
can be linked to by third parties and may be discoverable online for a number of years, if not permanently.
Search engines may also cache or retain copies of published information.
Permission to publish: I have read the information about disclosing and publishing student information
(above) and I give permission I do not give permission
for the Department to publish and disclose information about my child in publicly accessible communications.
This permission remains effective until I advise otherwise.

signed:
(Parent/Caregiver) (Date)

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 Student name:
New South Wales Combined High Schools Sports Association

6. Principal’s Declaration

• I certify that the student whose details appear on this form is enrolled at this school.
• I have verified that the date of birth as stated on this form is correct.
• He/she has the school authority to represent on this occasion.
• A copy of this consent form will be retained by my school.
• I certify this student has / has not parental / caregiver permission to publish as stated in the ‘Publishing
student information’ above

signed:
(Principal) (Date)

noted by:
(School Sports Organiser) (Date)

7. Parental Consent

I have read the information issued and I hereby consent to my child participating in this event.

I understand that my child will be under the supervision of Team Manager/s and will not be allowed to visit
friends or relatives without my written permission and that of the Team Managers.

I have sighted the enclosed Code of Behaviour and agree that if my child/ward seriously contravenes
behavioural expectations, he/she may be immediately excluded from the team. Should this eventuate, I accept
full responsibility for my child/ward upon notification of his/her exclusion by the team manager including the cost
of return transport and accommodation.

I understand in having a child represent this Association, I may be asked to billet a visiting student in the future.

In the event of any accident or illness, I authorise the obtaining, on my behalf, an ambulance and any such
medical assistance that my child may require. I accept full responsibility for all expenses incurred.

To assist team management at the Carnival and to the best of my knowledge, my child has no medical condition
or injury that places them at risk in participating in this sport activity.

signed:
(Parent / Caregiver) (Date)

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